Ambulatory Care Manager (RN)

Rochester Regional Health

1d•$80,753 - $110,292•Hybrid

About The Position

The central role of the RN Care Manager is a commitment to improve clinical outcomes in patient populations most at risk within practices and those at potential risk for adverse healthcare outcomes. The Registered Nurse works in collaboration with primary care providers and the multidisciplinary care team to identify and proactively manage the needs of patients with high risk or complex medical, behavioral health and/or psychological problems through practice, community and home-based visits and telephonic support. The RN Care Manager develops and implements a care management plan based on patient goals, preferences and disease states to promote improved health care outcomes and quality of life. The RN Care Manager links patients to appropriate community resources, facilitates referral to appropriate care services, supports patient self-management, and communicates with providers in order to reduce barriers to improved health care outcomes. The RN Care Manager serves as an integral member of the primary care practice's care team, assesses patients for risk of adverse health outcomes, and measures the impact of care management interventions. Provide superior customer service by modeling the Brand Promise and Core Values of the organization.

Requirements

For employees hired after October 1, 2020, requires an Associate’s Degree in Nursing (ASN) and a Bachelor’s Degree in another discipline - or a Bachelor's in Nursing (BSN).
Minimum 5 years of clinical nursing experience required.
BLS - Basic Life Support - American Heart Association (AHA)
RN - Registered Nurse - NYS Office of Professions

Nice To Haves

The BSN is preferred but not required.
Progressive clinical experience including community health, care management, disease management or behavioral health preferred
Compassionate, warm and patient focused
Strong interpersonal skills
Experience working as a member of a multidisciplinary team
Ability to lead and facilitate a team approach to population-based care
Critical thinking skills, decisive judgement
Exceptional documentation skills and professional behavior
Excellent written and verbal communication skills
Ability to work independently in a fast-paced environment
Proficient computer skills Excel, Word, the Internet and Health Information Technology

Responsibilities

Identify or work with others to identify patients with high risk of adverse health outcomes (e.g. death, disability, inpatient admission, SNF admission or ED visit.).
Engage patients in trusting relationships enabling effective intervention and support.
Conduct an assessment of patient condition, needs, preferences and clinical and psychosocial barriers.
Support the patient in identification of actionable goals to optimize health outcomes.
Develop a care management plan based on the patient's goals, strengths and barriers that promote improved health care outcomes and quality of life.
Provide culturally competent interventions based on member assessment and identified cultural needs.
Implement the patient approved plan of care in collaboration with the practice care team and patient through practice, community and home based visits and telephonic support:
Provide comprehensive care management including self-management support, health promotion, connection/referral to appropriate physical/mental health/substance abuse providers and community based organization social supports to decrease barriers to attending appointments and following the plan of care, red flag education, etc.;
Utilize Self-Management Support interventions to promote self-advocacy. Monitor the patient’s level of activation relative to their health goals over time.
Advocate for patients to assure access and timely service delivery across the continuum of care and community resources.
Provide education/ information to patients/caregivers in support of care plan goals.
Optimize insurance and other benefits to support patient access to needed services.
Provide care coordination with Primary/Specialty Medical care, acute and outpatient medical, mental health and substance abuse services, and other care managers involved in supporting the individual;
Provide comprehensive transitional care involving coordination of care and services post critical events, such as emergency department use, hospital inpatient admission and discharge or skilled nursing facility admission and discharge;
Work with the attending/consulting physicians to facilitate effective transition through timely communication of information necessary for patient care and discharge planning, and supporting appropriate patient self-management.
Provide crisis intervention planning addressing events such as emergency department visits or inpatient admissions or other crisis events to ensure planned crisis interventions are effective and to make necessary modifications of the Plan of Care or need for additional support services;
Conduct medication reconciliation as appropriate and communicate needs for adjustments to care team/provider;
Provide patient education; facilitate solutions to patient care /delivery problems;
Work with family regarding the patient’s needs; assess caregivers burdens; provide family and caregiver support;
Ensure language access/ translation capability;
Review patient progress no less frequent than quarterly;
Modify goals and care management interventions as appropriate to the needs/progress of the individual;
Share information (e.g. progress, barriers, new conditions, etc.) between Team members and other care providers;
Participate in Care Team meetings, training, and other functions as required
Meet practice policy and procedures related to documentation of care management activities and their effectiveness in a practice software tool;
Handle confidential information in accordance with HIPAA, state and federal privacy and confidentiality rules.
Foster a positive working relationship with patients, providers and practice staff;
Work effectively with others to coordinate patient and access care support services;
Provide input relating to changes that may enhance the practice effectiveness;
Participate in meetings and huddles as appropriate;
Conduct pre-visit planning and post-visit follow-up for care managed patients;
Provide feedback to providers regarding patient progress and barriers encountered;
Prepare for and participate in case review meetings to share cases, discoveries, concerns and collaborate in the development of plans of care.
Collect and provide reports of activities as required
Care Manager will participate in all scheduled meetings and training opportunities;
Shares updated information related to appropriate community resources
Identifies opportunities to improve processes and services. Shares with Practice and Leadership issues that are obstacles to meet patient need.
Performs other duties as assigned.
Work hours as scheduled, may require some evenings and weekend dependent upon population needs